Measles Case Report Form - Georgia Department Of Public Health
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1
2Georgia Department of Public Health
SendSS ID: ____________
Measles Case Report Form
Form Complete □ Yes □ No
PATIENT DEMOGRAPHICS
Patient name: Last, First
M.I.
Gender:
Date of birth
Age (enter age and check one):
(mm/dd/yy):
□
□
____/____/____
___ □ Days □ Weeks □ Months □ Years
Male
Female
Address: Number, Street
City:
State:
ZIP code:
County:
Home (
)
–
–
Country of birth:
Telephone number:
Work ( )
Ethnicity (check one):
Race (check all that apply):
□
Hispanic/Latino
□ Black/African-American
□ Asian /Pacific Islander
□ Unknown
□
Non-Hispanic/Latino
□ Native American/Alaskan Native
□ Multiracial
□
Unknown
□ White
□ Other (please specify) ______________________
TRACKING DATA
Medical record no. or client no.:
State Case ID (For state use only):
Date reported to health department (mm/dd/yy)
:
Date investigation started:
Person reporting:
Reporter telephone:
____/____/____
____/____/____
( ) –
Organization: Investigator phone:
Event Date:
Event Type:
Case investigator completing form:
□ Rash Onset Date
(
)
–
____/____/____
□Diagnosis Date □Lab Test Date □Unknown
□Report Date (County) □Report Date (State)
SIGNS AND SYMPTOMS
Rash onset
Origin on body
Direction of spread
Rash?
Rash duration Generalized rash?
date
□Yes □No □Unknown
___/___/____
_______days
□ Yes □ No □ Unknown
Highest recorded
Was temperature taken?
Fever?
Fever onset date
If temperature not taken, skin was
temperature
o
□ Yes □ No □ Unknown
□ Yes □ No □ Unknown
___/___/_____
____ . ___
F
□ Hot □ Warm □Normal □Unknown
Cough?
□Yes □No □Unknown Onset date ___/____/_____
Other symptoms?
Describe additional symptoms
Coryza?
□Yes □No □Unknown Onset date ___/____/_____
□ Yes
Conjunctivitis □Yes □No □Unknown Onset date ___/____/_____
□ No
Koplik's spots □Yes □No □Unknown Onset date ___/____/_____
□ Unknown
Does case meet clinical criteria for further investigation?
CASE MEETS CDC/CSTE CLINICAL CRITERA?
(FOR STATE USE ONLY )
□ Yes □ No □ Unknown
□ Yes □ No □ Unknown
COMPLICATIONS AND OTHER SYMPTOMS
Hospitalized?
Admission date
Discharge date
Date of death
Number of days
Died?
hospitalized ____
□ Yes □ No □ Unknown
____/____/____
____/____/____
____/____/____
□ Yes
Facility Name:
If died, complete and
attach measles death
□ No
Other complications?
Pneumonia?
Encephalitis?
worksheet
□ Yes □ No □ Unknown
□ Yes □ No □Unknown
□ Yes □ No □ Unknown
□ Unknown
Describe additional complications:
LABORATORY TESTS
Was laboratory testing for measles done?
Case lab confirmed
Virus isolated?
(For state use only)
□
□
□
□ Yes □ No □ Unknown
Yes
No
Unknown
□ Yes
□ No
□Unknown
Specimen sent to CDC for
Result
Date specimen taken
Lab name
Specimen Type
genotyping?
______
____/____/____
___________
____________________
Culture
□Yes □No □Unknown
______
PCR
____/____/____
___________
____________________
Date sent to CDC
___/___/______
IgG (acute)
______
____/____/____
___________
____________________
IgG (convalescent)
______
____/____/____
___________
____________________
Virus genotype
______________
______
IgM
____/____/____
___________
____________________
Result Codes: P:Positive X:Not done N:Negative I:Indeterminate E:Pending U:Unknown
Specimen Type Codes: U:Urine S: Blood/Serum N: Nasopharyngeal swab T: Throat swab O: Other U: Unknown
Comments:
Updated January 2015
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